results for purposes of medical underwriting.4 None of the responding companies reported that they had done any economic analysis of the costs and benefits of carrier testing or genetic tests as part of applicant screening, although one commercial company had done an analysis of prenatal coverage. Similarly, none of the companies reported any economic analysis of providing carrier screening or genetic counseling within their benefit package. However, the survey did confirm concerns about policies and practices of insurers regarding genetic testing for CF. "On balance, however, it appears that, for now, if no medical indication for the test exists, a third-party payer generally will not pay for the (CF screening) assay" (OTA, 1992a, p. 178) (see Table 7-1).

The Impact of CPT Codes on Reimbursement

CPT-4 (current procedural terminology) codes (standardized categories used for reimbursement of health services) do not exist for many genetic tests, since the technology is developing so rapidly. In the absence of CPT-4 codes, insurance reimbursement is not possible without special review by the insurer. Some genetic testing centers are using CPT-4 codes intended for biochemical precursors to seek reimbursement from insurers. As genetic testing becomes more widespread, the lack of CPT-4 codes for genetic testing and genetic counseling will be a major impediment to insurance reimbursement even for those people who have insurance coverage for genetic diagnosis (OTA, 1992c). A committee of the American Medical Association (AMA) establishes CPT codes, including the addition of new codes. Now that the new American College of Medical Genetics (ACMG) has been recognized by the American Board of Medical Specialties (ABMS) of the AMA, the ACMG may be able to influence the AMA committee responsible for CPT-4 codes to develop appropriate codes for genetic tests.


In some instances, public financing for genetics services occurs through Medicaid, Medicare, or state genetics services programs.


Medicare is primarily a program to reimburse medical expenses considered "medically necessary" for people over age 65 and certain categories of disabled persons. Medicare coverage decisions and reimbursement policies related to genetic testing now affect primarily the population of persons with disabilities, some of whom would find genetics services relevant and useful. In the future, Medicare may have a broader impact, as genetic tests are developed for more disorders common to older Americans, including complex common disorders such as heart disease, cancers, diabetes mellitus, and certain mental health disorders.

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